Standardization and Reflexivity: EPR implementation at Rikshospitalet

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Standardization and Reflexivity EPR
implementation at Rikshospitalet

• Edoardo Jacucci
• Department of InformaticsUniversity of
  OsloNorway

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Aims of the lecture

• See case of complex standardization
• Installed base of 100s of systems/practices
• Type of organization highly specialized hospital
• Study stdzation strategies and their side-effects
• Adopt II perspective to interpret the case
• Focus on Reflexivity

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Content

• Part 1 the case
• Part 2 analysis from II perspective and
  reflexivity
• Part 3 about stdization strategies

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About Rikshospitalet
Part 1 Case

• Quaternary (highly specialized) national hospital
• 17 clinical departments
• 100s of systems
• Department systems
• Cross-department systems
• Hospital-wide systems
• Three stages of IT infrastructure management
• - 1995 LAN maintenance and support
• 1995 2003 EPR clinical systems integration
• 2003 future CASM process approach loose
  integration

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Stages of management of the II
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What is an EPR
Part 1 Case

• Storing Clinical Information
• Structured Standardized Presentation
• Accessibility Availability Redundancy
  Consistency
• Workflow
• System Integration
• Centralized Integrated Standardized Information
  Control System

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What is an EPR
Part 1 Case

• Stakeholders
• Doctors, Nurses, Secretaries (users)
• IT Department
• Vendor
• Hospital Administration
• Government (Ministry of Health)
• International Institutions (Cooperation/Standardiz
  ation)

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From paper to DB
Part 1 Case
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EPR as a standard
Part 1 Case
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EPR as Infrastructure
Part 1 Case

• II evolving, shared, open, heterogeneous,
  installed base
• II as a Complex System
• Number of actors
• Interdependecies
• History
• Network Externalities, Path Dependecy, Lock-in,
  Side-effects, Reflexivity

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Case study four stories
Part 1 Case

• From unity to fragmentation
• Between vision and reality
• The time bomb
• Crisis at the archive
• The quest for integration
• Integrating needs more integration
• Going Global
• Fight risk with risk, mitigate complexity with
  complexity

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From Unity to Fragmentation
Part 1 Case
?
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From Unity to Fragmentation
Part 1 Case
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Crisis at the Archive
Part 1 Case

• 1995 Centralizedand Standardized Paper Record
• 2003 8000 shelf meters (sm)
• Annual growth 1200 sm
• Now 300 sm on the floor
• 800 requests/day
• 30 requests not fulfilled

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Crisis at the Archive
Part 1 Case

• Time bomb
• EPR and Paper Record run in parallel
• EPR used for printing (inefficient)
• Lousy update routines for incomplete integration
• EPR gt Increased Paper Budget
• EPR gt Worsen Archive Crisis

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The Quest for Integration
Part 1 Case
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Part 1 Case
Adv. in The Economist, Oct 11th-17th 2003
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Going Global
Part 1 Case
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Analysis Side-effects of Standard-making
Part 2 Analysis
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Reflexivity
Part 2 Analysis

• Integration requires more integration
• Standardization requires more standardization
• Managing complexity increases complexity to be
  managed
• WHY?
• Is it always like this?
• Under what conditions?
• What can we do about it?

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Reflexive Modernization (Beck)
Part 2 Analysis

• Modernity feeds back to itself, exacerbating and
  possibly undemining its own foundations

Modern Society
Rationalization Control
Undemine
Increased Complexity
Unintended Consequences
Increased Unawareness
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Reflexive Standardization Process
Part 2 Analysis
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Reflexivity
Part 2 Analysis

• WHY?
• Happens ever more often in our modern
  (increasingly interconnected) society
• Is it always like this?
• No, in smaller, general hospitals EPR
  implementation may be smoother.
• Under what conditions?
• High level of interdependencies and sheer number
  ot actors
• High degree of specialization and diversity
• High level of complexity
• What can we do about it?
• Lets see what Rikshospitalet did

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Managing the Infrastructure
Part 3 Strategy

• Strategy so far
• Interdisciplinarity
• Corresponsibility
• Openness
• Improvisation/Bricolage
• Politics
• Cultivation
• But Risks
• Escalation
• Control Crisis
• Enron syndrome

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Conclusions
Part 3 Strategy

• Standardization as control of complex reality
• Paradoxical outcomes
• Interpretation as side-effects
• Mechanism Reflexive property of standardization